DOI: 10.7860/JCDR/2013/4834.

3032
Case Report

Tuberculous Salpingitis: A Case Report

Obstetrics & Gynaecology

Section
Annie Rajaratnam, Prema DCunha, Zevita Furtado, Hilda Fernandes

ABSTRACT
Tuberculosis (TB) of the genital tract commonly occurs secondary
to a primary lesion. The mode of spread is via the lymphatics, the
haematogenous route or less commonly by a peritoneal spread. The
fallopian tubes are the first targets, followed by the pelvic organs.
Isolated cases of TB which occur in a unilateral fallopian tube are
rare, particularly with it as a primary site. The aim of this study was
to report a rare case of TB of the left fallopian tube in a post meno-
pausal lady with no positive history, clinical or laboratory finding to
suggest it to be a secondary focus. As the pre-operative diagnosis
was that of a right ovarian neoplasm, the patient underwent stag-
ing laparotomy. TB of the left fallopian tube was diagnosed, as there
were numerous typical granulomata throughout the fallopian tube.

Key Words: Tuberculous salpingitis, Genital tuberculosis, Primary foci

Introduction
The prevalence of genital TB in the female population is 1-2% [1].
Genital TB is difficult to diagnose, as most of the cases are asymp-
tomatic [2] and as they usually occur between the ages of 20-40
years. The women with genital TB may present with low grade
fever, pelvic pain, menstrual irregularities, infertility and secondary
amenorrhoea [3]. Genital TB begins simultaneously in both the fal-
lopian tubes and then it spreads to the rest of the genital tract [4]. [Table/Fig-1]: Per operative findings showing torsion of right ovarian
The ampullary region shows the earliest and the most extensive cyst
changes [5]. Primary tuberculosis of the fallopian tube is rare.

Case Report
A 55 years old, P4L4, post menopausal lady presented with lower
abdominal pain of two weeks duration. The pain was dull and con-
tinuous. She had no fever, weight loss or abnormal vaginal dis-
charge. She had no past or family history of TB.

On examination, her Body Mass Index (BMI) was found to be [Table/Fig-2a]: Scanner view showing thinned wall of the tube (arrow)
28 and her other systems were normal. P/A: A 20x18 cm cystic and flattened epithelial folds with inflammation
mass was felt in the right iliac fossa, which arose from the pel-
vis and there was no free fluid. P/S: The vagina and the cervix
were healthy. P/V: The uterus was normal in size and mobile and
a right adnexal mass of 20x18 cm was felt. The left fornix was free.
Investigations: Hb: 11gms%, Total count: 6500 and ESR:17mm/
hr. The liver and renal function tests were normal. CA-125 was
82.38u/ml. The urine culture showed no growth. The PAP smear
was negative for malignant cells. The chest X-ray was normal. The [Table/Fig-2b]: Scanner view of the other portion of the tube showing
congested peritubal vessels (arrows) and similar features as in [Table/
ultrasound showed a mixed echoic mass of size, 10.5 x 5 x 5.7 cm Fig-2a]
in the right ovary. CT scan showed a 10.5 x 8 x 8.5cm right ovar-
ian mass with mixed echogenecity. The lymph nodes were normal,
with minimum free fluid in the abdomen. The risk malignancy index
(the ultrasound features x the menopausal state x the value of CA-
125) was 247.14. The preop diagnosis being that of an ovarian
neoplasm, the patient was posted for a staging laparotomy. The
per operative findings showed a right ovary of size, 10 x 8 x 8cm
with torsion. The right fallopian tube, the uterus and the left adnexa
[Table/Fig-2c]: High power view showing multiple epitheloid
were normal. [Table/Fig-1]. There was minimum free fluid. The rest
granulomas (arrow) and langhans type of giant cells (star)
of the abdomen was normal.
1186 Journal of Clinical and Diagnostic Research. 2013 June, Vol-7(6): 1186-1188
www.jcdr.net Annie Rajaratnam et al., Primary Tubal Tuberculosis
[Table/Fig-3]: Microscopic appearance of tuberculous lymphadenitis of
the pelvic lymph node
Histopathology: The peritoneal fluid was negative for malignant
cells and Acid Fast Bacilli (AFB). The cervix showed chronic cervi-
citis and the endometrium revealed senile cystic atrophic changes.
The right ovary showed diffuse areas of haemorrhage and infarc-
tion with a rim of viable ovarian stroma. The right tube and the left
ovary were normal. The left tube showed the presence of multiple
granulomas which were composed of aggregates of epithelioid
histiocytes with scattered small lymphocytes and the Langhans
type of multinuclear giant cells [Table/Fig-2a]. A scanner view which
is showing the thinned wall of the tube (arrow) and the flattened
epithelial folds with inflammation [Table/Fig-2b]. A scanner view of
other portions of tube which is showing the congested peritubal
vessels (arrows) and similar features as in [Table/Fig-2a], [Table/
Fig-2c]. High power views showing multiple epitheloid granulomas
(arrow) and the Langhans type of giant cells (star).
The pelvic lymph nodes showed granulomatous lymphadenitis
which was suggestive of TB [Table/Fig-3]. The microscopic ap-
pearance was of tuberculous lymphadenitis of the pelvic lymph
node, but AFB was negative. The omentum and the appendix were
unremarkable. The post operative period was uneventful. Multidrug
therapy is the main stay of the treatment and a short term treat-
ment with antitubercular drugs for 6 months is effective for genital
TB. Hence, the patient was started on the Category I treatment of
Directly Observed Treatment Short Course (DOTS) ie. 2 (HRZE)3
as the intensive phase and 4 (HR) 3 as the continuation phase
regimen, as it was considered to be a case of primary tubercular
salpingitis.
Discussion
The view that TB of the pelvic organs varies geographically, ethni-
cally and with the type of patient, is a reflection of the lacunae in the
knowledge and paucity of good studies [3]. Morgagni was the first
to describe the signs of genital TB in women [2]. The wide variabili-
ty in the extent and the site of the disease is due to the investigative
procedures/techniques which are used [3]. Genital TB is always
secondary and the patient may be unaware of the primary focus
that is extragenital, which may most commonly be a pulmonary
lesion [6]. Gynaecologists need to be aware that TB may present
in an atypical manner. Genital TB is called the great pretender
because it resembles the presentation of advanced ovarian carci-
noma [7]. Though a microbiological proof is essential, the authori-
ties may accept a histopathological proof (typical granuloma) to
confirm the diagnosis of TB [8].
The criteria which are necessary for a diagnosis of primary genital
TB are (1) the genital lesions should be the first tuberculous infec-
tions in the body and (2) the regional lymph nodes should demon-
strate the same stage of the tuberculous development as do the
genital organs [9]. Our case fulfilled both the criteria and hence, it
was considered as a primary focus, as there was no history, clini-
Journal of Clinical and Diagnostic Research. 2013 June, Vol-7(6): 1186-1188
cal features or investigations to prove the involvement of any other
organs or systems. Serum CA 125 is raised in peritoneal TB and
in benign intra-abdominal conditions [10]. The raised CA 125 with
active TB may be misinterpreted as ovarian cancer [7]. The tubes,
ovaries and the serosal surface of the uterus may be involved in the
peritoneal spread which originates from an intra abdominal lesion
[2]. Our case did not have any intra-abdominal lesion.
Unilateral primary tubal TB is extremely rare, but due to the ab-
sence of a peritoneal lesion, tuberculosis of the fallopian tube is
likely to be primary in origin [11] as in our case. Although culture
methods are still the gold standard in the detection of genital tuber-
culosis, they are negative in one-third of the cases [12]. However, in
the presence of risk factors/suggestive intra operative findings, the
testing for TB in this set of the population who present with ectopic
pregnancies may be justified, to prevent further morbidity, by initiat-
ing anti-tubercular therapy in the high prevalence areas [13].
A primary infection may occur if the male partner has active genito-
urinary TB and the transmission is by sexual intercourse. In post-
menopausal women, genital TB is rare and it constitutes 1% of
the cases of postmenopausal bleeding. Our case did not have any
history of a vaginal discharge, which correlated with the review
reports of Gungorduk K et al., [14]. The exact cause of the low in-
cidence of the disease in this age group is not known. Most of the
authors believe that an atrophic endometrium is a poor milieu for
the growth of the Mycobacterium tuberculosis bacilli [15].
Surely the future of a better and a reliable early diagnosis of geni-
tal TB lies in the development of a multiplex Polymerase Chain
Reaction (PCR). A combination of suitable primers which target
the repetitive sequences and the species specific gene sequences
would be ideal, to detect more number of cases. A good history
taking, along with a correct sampling with the use of various im-
aging modalities and the use of multiplex PCR, will certainly turn
around the diagnostic difficulty of genital TB [16]. Thus, pelvic TB
should be considered as a possibility in the women who present
with a pelvic mass, in the absence of fever, ascites, and an el-
evated CA-125 level.
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AUTHOR(S): NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING
1. Dr. Annie Rajaratnam AUTHOR:
2. Dr. Prema DCunha Dr. Annie Rajaratnam,
3. Dr. Zevita Furtado Assistant Professor, Department of Obstetrics & Gynaecology,
4. Dr. Hilda Fernandes Father Muller Medical College, Kankanady, Mangalore-575002,
Karnataka, India.
PARTICULARS OF CONTRIBUTORS:
Phone: 9449525915
1. Assistant Professor, Department of Obstetrics &
E-mail: annierajaratnam@yahoo.com
Gynaecology, Father Muller Medical College, Mangalore-
575002, Karnataka, India. Financial OR OTHER COMPETING INTERESTS:
2. Professor, Department of Obstetrics & Gynaecology, Father None.
Muller Medical College, Mangalore-575002, Karnataka,
India.
3. Final Year Resident, Department of Microbiology, Father
Muller Medical College, Mangalore-575002, Karnataka,
India. Date of Submission: Jul 15, 2012
Date of Peer Review: Nov 11, 2012
4. Professor, Department of Pathology, Father Muller Medical Date of Acceptance: Mar 27, 2013
College, Mangalore-575002, Karnataka, India. Date of Publishing: Jun 01, 2013

1188 Journal of Clinical and Diagnostic Research. 2013 June, Vol-7(6): 1186-1188